Management of Patients Treated with Direct Oral Anticoagulants in Clinical Practice and Challenging Scenarios

Abstract

It is well established that direct oral anticoagulants (DOACs) are the cornerstone of anticoagulant strategy in atrial fibrillation (AF) and venous thromboembolism (VTE) and should be preferred over vitamin K antagonists (VKAs) since they are superior or non-inferior to VKAs in reducing thromboembolic risk and are associated with a lower risk of intracranial hemorrhage (IH). In addition, many factors, such as fewer pharmacokinetic interactions and less need for monitoring, contribute to the favor of this therapeutic strategy. Although DOACs represent a more suitable option, several issues should be considered in clinical practice, including drug–drug interactions (DDIs), switching to other antithrombotic therapies, preprocedural and postprocedural periods, and the use in patients with chronic renal and liver failure and in those with cancer. Furthermore, adherence to DOACs appears to remain suboptimal. This narrative review aims to provide a practical guide for DOAC prescription and address challenging scenarios.

Italian Association of Hospital Cardiologists Position Paper ‘Gender discrepancy: time to implement gender-based clinical management’

“…Lastly, antiplatelet and anticoagulant strategies in women should be appropriately employed. 325 , 326 …”

Coagulation Tests and Reversal Agents in Patients Treated with Oral Anticoagulants: The Challenging Scenarios of Life-Threatening Bleeding and Unplanned Invasive Procedures

“…In the Tromsø Study, the utilization of OACs has been linked to increased mortality rates related to ICH [38]. The data concerning the prognostic impact of hematoma expansion or bleeding volumes in patients treated with DOACs or VKAs are heterogeneous [39][40][41][42][43][44]. Any difference in ICH volume, 90-day rate of hematoma expansion, or all-cause mortality between DOACs or VKAs has been shown [39].…”

“…Since ICH in anticoagulated patients represents a life-threatening scenario, the development of a tool capable of promptly identifying anticoagulated patients at heightened risk of experiencing ICH could be of paramount importance [44]. In this context, Park et al performed the Hemorrhage Estimate Risk in Oral Anticoagulation for Mild Head Trauma (HERO-M) score on a cohort comprising 1425 patients receiving DOACs [45].…”

“…Although specific studies to assess the management of anticoagulated patients with ICH are unavailable, the Swiss Society of Hematology has recently provided some recommendations [44,46,47]. Specifically, in the presence of ICH, andexanet alfa has been suggested in those patients without severe neurological impairment (Glasgow Coma Scale >7), with symptom onset occurring in less than sixh, life expectancy >1 month, and last intake of apixaban/rivaroxaban <15 h or anti-Xa >100 ng/mL.…”

Primary Care Clinicians’ Prescribing Patterns of Reduced-Dose Direct Oral Anticoagulants for Extended-Phase Venous Thromboembolism Treatment

“…Dose-reduction studies have not been conducted with dabigatran or edoxaban [ 11 ]. However, in certain clinical situations such as in the case of VTE and cancer [ 12 ], obesity [ 13 , 14 ], or when new thrombosis occurs among patients taking a reduced dose of anticoagulation, patients are perceived as being at an especially high risk for recurrent thrombosis [ 15 ]. Limited evidence informs whether dose reduction is appropriate in these populations.…”